Utilization Management Nurse - Case Management

CHRISTUS Santa Rosa Hospital - Westover Hills (CSRH-WH) is a 253-bed hospital serving the fastest- growing area of San Antonio. Specialized care includes orthopedic and surgical care with advanced spine surgery, Intensive Care, complex neurology for treating stroke and other neurovascular issues, comprehensive cardiovascular care from diagnostics to open heart surgery, vascular lab, sleep center, women’s services, a newborn nursery, the CHRISTUS Weight Loss Institute, wound care, rehabilitation, emergency services, and more. The campus also boasts an Outpatient Imaging Center, an Ambulatory Surgery Center, and four medical plazas, one of which houses our CHRISTUS Santa Rosa Family Medicine Residency Program and CHRISTUS Santa Rosa Family Health Center.

Summary

The Utilization Management Nurse PRN is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List).

They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care. Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services.

Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance. Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations. Coordinate and facilitate correct identification of patient status.

Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care. Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses. Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i.e.

IMM, Code 44. Demonstrate adherence to the CORE values of CHRISTUS. Utilize independent scope of practice to identify, evaluate, and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards. Take appropriate follow-up action when established criteria for utilization of services are not met.

Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance. Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews. Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.

Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i.e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.) Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate. Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials. Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services.

Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care. Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice. Analyze assessment data to identify potential problems and formulate goals/outcomes.

Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI). Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate. Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.

Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change. Translate strategies into action steps; monitor progress and achieve results. Demonstrate the confidence, drive, and ability to face and overcome challenges and obstacles to achieve organizational goals.

Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department. Possess negotiating skills that support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers. Excellent verbal and written communication skills, knowledge of clinical protocol, normative data, and health benefit plans, particularly coverage and limitation clauses.

Must adjust to frequently changing workloads and frequent interruptions. May be asked to work overtime or take calls. May be asked to travel to other facilities to assist as needed.

Must have excellent verbal and written communication and ability to interact with diverse populations. Must have critical and analytical thinking skills. Must have demonstrated clinical competency.

Must have the ability to Multitask and to function in a stressful and fast-paced environment. Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. Must have an understanding of pre-acute and post-acute levels of care and community resources.

Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families. Must have an understanding of internal and external resources and knowledge of available community resources. Must have familiarity with criteria sets including InterQual and MCG preferred.

Other duties as assigned.

Job

Requirements

Education/Skills

Graduate of an accredited school of nursing required.

Experience

A minimum of 2 years in acute clinical practice as a nurse. Case Management and Utilization Review experience preferred.

Licenses, Registrations, or Certifications

LVN/LPN or RN License in state of employment or compact required. BLS certification preferred. Certification in Case Management preferred.

Work Schedule

PRN

Work Type

Per Diem As Needed